CMS/EIP Fiscal Report Center: 04
Services beginning 01/01/2008 ending 12/31/2008 Date of Report:02/16/2009 Page: 1
Payclass Filters:GR
Eligibility Filter:Not Part C
List order: No List
Services Number of Number of Fee Reported Avg Fee
Children Units Per/Unit
Service Coordination,Class #01
CASE-CASE-NON-TCM CASE MANAGEMENT 200 91.75 3394.75 37.00
IFSP-IFSP-INDIVIDUALIZED FAMILY SUPPORT PLAN 370 376.00 0.00 0.00
SCTT-SCTT-SERVICE COORDINATOR TRAVEL 57 35.75 1322.75 37.00
TCM-T1017TL-TARGETED CASE MANAGEMENT 202 1250.50 46268.50 37.00
Subtotal (Total Children Is Unduplicated) 392 1754.00 50986.00 29.07
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Screening, Eval, and Assessment,Class #02
IPDEF-T1024GNTS-F/U PSYCH AND DEV EVAL BY SPAT 5 4.00 300.00 75.00
IPDEF-T1024GPTS-F/U PSYCH AND DEV EVAL BY PT 1 0.50 37.50 75.00
IPDEF-T1024TLTS-F/U PSYCH AND DEV EVAL BY EI PROF 4 5.00 375.00 75.00
IPDEF-T1024TS-F/U PSYCH AND DEV EVAL BY ITDS 6 7.50 416.25 55.50
IPDEI-T1024GNUK-INITIAL PSYCH AND DEV EVAL BY SPAT 120 95.00 7125.00 75.00
IPDEI-T1024GOUK-INITIAL PSYCH AND DEV EVAL BY OT 3 3.00 225.00 75.00
IPDEI-T1024GPUK-INITIAL PSYCH AND DEV EVAL BY PT 55 47.50 3562.50 75.00
IPDEI-T1024HNUK-INITIAL PSYCH AND DEV EVAL BY ITDS 238 234.00 12987.00 55.50
IPDEI-T1024TL-INITIAL PSYCH AND DEV EVAL BY EI PROF 187 204.00 15300.00 75.00
MED-99203-OUTPATIENT VISIT, NEW, 30 MINS 35 35.00 6475.00 185.00
Subtotal (Total Children Is Unduplicated) 335 635.50 46803.25 73.65
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EI Services,Class #03
TRAN-TRAN-FAMILY TRANSPORTATION 307 325.00 2322.50 7.15
Subtotal (Total Children Is Unduplicated) 307 325.00 2322.50 7.15
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Total 2714.50 100111.75 36.88
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Number of Children (Unduplicated) With at Least One Service 393
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Center 04
Flag Claims Units Chgs Paid
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R 0 0.00 0.00 0.00
U 0 0.00 0.00 0.00
B 0 0.00 0.00 0.00
P 1 0.25 9.25 9.25
D 55 63.25 6780.25 1230.25
S 0 0.00 0.00 0.00
H 0 0.00 0.00 0.00
T 0 0.00 0.00 0.00
2494 2651.00 93322.25 0.00
Other 0 0.00 0.00 0.00
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Total 2550 2714.50 100111.75 1239.50